What's Happening?
Kaiser Permanente affiliates have agreed to pay $556 million to resolve allegations of violating the False Claims Act. The allegations involve submitting invalid diagnosis codes for Medicare Advantage Plan enrollees to receive higher payments from the government.
The affiliates involved include Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan of Colorado, and several Permanente Medical Groups. The U.S. government alleged that Kaiser pressured physicians to alter medical records post-visit to add unconsidered diagnoses, thereby inflating risk adjustment payments. This practice was said to occur from 2009 to 2018, with Kaiser allegedly setting aggressive goals for adding risk adjustment diagnoses and linking financial incentives to these goals. The settlement resolves claims brought under the False Claims Act's whistleblower provisions by former Kaiser employees, with a $95 million share of the recovery going to the whistleblowers.
Why It's Important?
This settlement underscores the U.S. government's commitment to combating healthcare fraud, particularly within the Medicare Advantage program, which serves over half of the nation's Medicare beneficiaries. The case highlights the financial implications of fraudulent practices on public healthcare funds, costing taxpayers billions annually. By holding healthcare providers accountable, the government aims to ensure the integrity of Medicare payments and protect public resources. The resolution serves as a warning to other healthcare organizations about the consequences of submitting false information to inflate profits, emphasizing the need for transparency and compliance with federal regulations.
What's Next?
Following the settlement, Kaiser Permanente and other healthcare providers may face increased scrutiny from federal agencies to ensure compliance with Medicare regulations. The case may prompt other healthcare organizations to review their practices to avoid similar allegations. Additionally, the settlement could lead to more whistleblower actions as employees become more vigilant in reporting fraudulent activities. The government is likely to continue its efforts to strengthen oversight and enforcement of healthcare fraud laws, potentially leading to further legal actions against non-compliant entities.
